Provider Demographics
NPI:1588824817
Name:KULM MEDICAL PA
Entity Type:Organization
Organization Name:KULM MEDICAL PA
Other - Org Name:LIBERTY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-275-7200
Mailing Address - Street 1:4301 SATURN RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-5323
Mailing Address - Country:US
Mailing Address - Phone:214-275-7200
Mailing Address - Fax:214-703-3354
Practice Address - Street 1:4301 SATURN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5323
Practice Address - Country:US
Practice Address - Phone:214-275-7200
Practice Address - Fax:214-703-3354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2503111N00000X
TX10858111N00000X
TX4175111N00000X
TXE71142081P2900X
TXH2662208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty